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Presidential leadership or structural constraints? The failure of President Carter's health insurance proposals.

This study explores presidential leadership in domestic policy by assessing how Jimmy Carter, working with a Democratic majority in Congress, dealt with health care reform. This article will explore how the personal style, organizational arrangements, and leadership abilities of the president and his advisers affected the legislative success of his health program. These factors will be contrasted with structural constraints--political, economic, and institutional--as explanations for the failure of President Carter's national health program. The article begins with an overview of previous assessments of Carter's leadership as it affected his activities in office. I then respond to Gary Reichard's call to test assumptions about Carter's leadership against the detailed record from the archives of the Carter presidential libraries.(1) Several key themes will be analyzed: presidential leadership in Congress, timing of proposals, administration unity, congressional alliances, and flexibility in negotiations. The article also assesses how contingencies and crises in the economy and politics constrained leadership. The author evaluates a view of Carter as ineffectual (an "agency" approach) and as a president constrained by uncontrollable political and economic conditions (a "structuralist" alternative). This analysis raises doubts over Carter's commitment to health reform and questions whether his inaction reflected his preference for limited action, not bold initiatives, in this field.

Jimmy Carter as the "Principled Outsider"

Assessments of Carter often focus on his personality and psychology as the "principled outsider." Carter displayed a disdain for politics as usual and a strong sense of a leader's responsibility to speak for the "public interest" and to eschew concessions to powerful interests.(2) During the 1976 election campaign, Carter ran as a challenger to the insiders in Washington and the moral degeneration that had developed within government in the Watergate era. Carter drew on popular disaffection with government and alarm over the power of narrow interests.(3) But Carter also had to bring traditional Democratic constituencies into a winning coalition and consequently had to deal with them once elected. His effort to maintain relations with powerful interests and yet to convince the public of his sincere plan to reform the system contributed to an appearance of vacillation. Many analysts argue that his preference for challenging rather than placating special interests, and for principled stands rather than pragmatic programs, led to his failures on issues like health care. Preoccupied with self-interested factions in Congress, Carter could not accommodate them, a critical problem in a post-Watergate Congress, with many "resurgent and individualistic" leaders.(4)

Carter's decision-making style emphasized extensive study and evaluation of options, aiming at a consensus in favor of a comprehensive, rational solution. Carter insisted on thorough and wide-ranging investigations and discussions among diverse actors with competing views. He felt that reasoned study and discussion would produce solutions to complex problems even where competing principles were at work He did not favor concessions to legislators or interests, and "compromise was acceptable only after an all out effort to sell the optimal policy had failed."(5) Carter did not base public appeals on a vision of social justice, focusing on a more pragmatic managerialism. He used populist appeals to the poor, conservative rhetoric respecting rural and family values, and modernization themes. His philosophy combined Christian humanitarianism with scientific inquiry. This makes it difficult to typecast his views and produces charges of deviation from principles. Carter's centrist orientation made him resist attempts to steer administration policies to the Left or Right. This created dilemmas for Carter, who sought solutions that balanced popular interests with fiscal responsibility, reflecting the post-oil crisis malaise and the impact of Vietnam and the Great Society. Efforts to balance fiscal constraint with new programs like health insurance prompted conflicts in the administration, and a public perception of indecision. By selecting policies that appealed to business to avoid looking too liberal, Carter delayed action on issues like the health program, which might have won support from liberals in the Democratic Party.(6)

These ideological preferences and leadership styles affected the design of White House structures in domestic policy formation. Carter reduced the centralization of domestic policy in the White House Domestic Council and returned responsibility for policy development to the departments. Carter believed strong Cabinet officers would improve efficiency in government operations, reduce secrecy, and provide better programs at lower cost. Carter relied on ad hoc groups of agencies and cabinet officers to develop ambitious policies like national health insurance.(7) The Domestic Policy Staff (DPS), headed by Stuart Eisenstadt, coordinated initiatives across departments but could not impose solutions on recalcitrant agencies. Its generalist staffers were not skilled in detailed cost-benefit analysis of policy and had to rely on departments and congressional offices for studies of program feasibility. As a result, coordination of domestic policy was minimal, and cabinet officers became "baronial" and competitive. Carter's approach allowed many competing viewpoints access to the highest decision-making circles but provided no authority to the White House staff to impose decisions. Cabinet officers and departments developed policies that deviated from Carter's goals. Facing cabinet divisions, Carter was not prepared for political "give and take," and he was frustrated when Congress did not accept his rational policy solutions.(8)

Many observers conclude that the Carter presidency failed because of these leadership and organizational traits.(9) They emphasize, like Bernard Kaufman, that the nation was not "ungovernable" and that Carter was "mediocre" in his failure to generate popular and congressional support for major policy changes. A more effective leader could have better used his opportunities and overcome obstacles. In Kaufman's judgement, "there is a political process in any system of representative government which no leader can simply ignore on the basis of being above the fray."(10) Carter's "apolitical" style of governing and his attempt to avoid the untidy compromises of politics hindered his ability to work with others to obtain results. As his own press and communications advisers acknowledge, Carter was unable to articulate his vision in a way that proved persuasive to Americans or Congress.(11)

Jimmy Carter as a "Prisoner of the Times"

Other analysts highlight congressional institutions and political and economic conditions as constraints on "nonincremental" presidential policy proposals like health care reform. As Michael Genovese suggests, Carter's failures reflected not only a lack of skill but also the challenges of governing in an "age of limits."(12) When Carter came to office, the national economy was in decline, with the post-oil embargo paradox of "stagflation"--low productivity and employment, coupled with high inflation. Declining performance lessened tax revenues while the costs of Vietnam and the Great Society strained government coffers. Carter had to worry about the political implications of these economic pressures and decided that inflation was the greater threat, making him cautious about spending. But he sought solutions to domestic problems within fiscal limits. This balancing of ideology, group pressures, and fiscal frugality created programs that were "too conservative for liberals and too liberal for conservatives."(13) As the election loomed, Carter solved dilemmas of growth and social justice by abandoning the latter.(14)

Political conditions were also not auspicious. Public distrust of government and the president had never been greater, with the fall of the imperial presidency after Watergate. Congressional leaders, fresh from their triumph over Nixon, were flexing their muscles and were not receptive to presidential entreaties. Moreover, the Carter victory was narrow, lessening his credibility. This emboldened opponents and challengers like Kennedy and Labor, who believed their support was crucial to Carter's victory and that he should pursue a liberal platform. This weakness did not facilitate principled leadership, since Carter lacked the influence to sway Congress to his position.

Political structure also did not facilitate leadership. The division of powers has always posed challenges for presidents, but reforms in the 1970s made Congress even less manageable. The power of committee chairs was diluted, and subcommittees assumed more importance; party unity declined and the diversity of interest groups escalated. These changes forced presidents to develop supportive coalitions among legislators with fewer ties to the White House and under increased scrutiny from media and special interests.(15) These new conditions gave more opportunities to opponents to block White House initiatives. David Banta noted that fragmentation of responsibility among nine committees and subcommittees, complex budgeting procedures, and lobbyists' power in health care made adoption of an ambitious rational system unlikely.(16)

Thus, it was not the most auspicious time to pursue grandiose new programs, even if Carter's personality and style had dictated this. Some analysts posit a structuralist approach, arguing that the president can only succeed when the economy is growing. Grover describes the presidency as a "contingent" office, dependent on "the dynamic interaction of state power and economic vitality."(17) Carter faced Congress' reassertion of power and economic stagnation, promoting a crisis of ineffectiveness. As Grover and Peschek argue, inflation, high interest rates, fiscal constraint, business resistance to spending, and growing conservative political strength meant that Carter "was every bit as much of an economic hostage as the Americans held in Iran were political captives."(18) Given these constraints, Carter's accomplishments, such as the Panama Canal treaty, civil service reform, and environmental and energy legislation, were remarkable. Hence, a focus on personality and leadership style may not do justice to Carter. A broader perspective must take account of political and economic constraints in the 1970s. This case study will evaluate whether Carter's leadership deficiencies or insurmountable economic and political circumstances best account for inaction in health care.

The Carter Administration and National Health Insurance

The Medicare program of 1965 stopped short of comprehensive coverage of hospital and physicians' care. Democratic Party factions and a coalition led by the United Automobile Workers (UAW), backed by religious, charitable and consumer groups, promoted universal public health insurance coverage.(19) To woo these groups, Carter made health care a domestic priority in the 1976 campaign. He promised "universal and mandatory" health insurance, funded by payroll taxes, with comprehensive benefits for all.(20) Carter's liberal advisers and supporters tried to hold him to his pledge. Yet, there was no effort to launch this measure during the first weeks of the new presidency. Carter's obsession with planning led to development of four different health insurance models in the Department of Health, Education and Welfare (HEW), which polarized the administration into factions. A fixation with inflation and fiscal restraint and fear of business and professional opposition convinced many advisers to block a National Health program.(21) This indecision hindered development of support in Congress by alienating figures like Kennedy, while preventing timely creation of a coalition in favor of a fiscally conservative plan.

Despite his promises, Carter's national health program took a backseat to other initiatives. Carter underestimated the complexity of the legislative process, and

had a long laundry list of domestic and foreign policies, but no

program--that is, no clear sense or indication of priorities between what

was more important and what was less important, what policies would be

compromised or given up to ensure the adoption of what other policies.(22)

Yet, this massive effort was not undertaken in a crisis or by a president with strong support. Legislation jammed committees, dissipated goodwill in Congress, and overwhelmed White House staffers. National Health Insurance (NHI) was a lower priority than economic stimulus, the Panama Canal treaties, government reorganization, energy conservation, budgetary and tax reform--the policies of the outsider challenging Washington. Carter first sought hospital cost containment despite objections from liberals like James Corman and Kennedy By the time a task force was set up, hospital administrators had stirred resistance in Congress.(23)

Action on NHI was slow. HEW produced four proposals on the basis of competing Congressional bills and developed a liaison with the White House DPS in April. On September 19, 1977, Eizenstat indicated that a proposal would not be released until 1978. In late fall, a meeting was arranged to discuss NHI among the White House, HEW, the Office of Management and Budget (OMB), and other agencies. But social groups were not brought in to shape policy or lobby Congress.(24) Peter Bourne, Carter's health adviser, warned that little work had been done and the plan would not be ready on time. Supporters like Kennedy and Vernon Jordan raised doubts about Carter's commitment. Bourne warned Hamilton Jordan that Carter had allowed the initiative to swing to Kennedy, and he urged Carter to raise his profile on this issue before sending a bill to Congress.(25) These delays lasted over a year, wasting the "honeymoon" period when tough measures were easier to implement.

Carter allowed HEW to take the lead with its Advisory Committee on National Health Insurance. HEW jealously guarded its role as lead agency, treating the White House liaison as an "observer" to its committee. Eizenstat reported that "HEW refuses to permit White House involvement at all, let alone direct control.(26) By late 1977, the "spirit of detente" between HEW and White House officials dissipated: "HEW has made clear ... that there will be no informal interchange between staffs, and that we will see nothing other than formal submissions to the President and other agencies."(27) Bourne warned of a "lack of commitment to National Health Insurance within the Administration" and called on Carter to direct his agencies to develop a consensus on the program.(28) But the secretary of HEW, Joseph Califano, urged Carter to remain aloof, to prevent political problems from this controversial issue.(29) There was no consensus on fundamental issues like the role of state, private and local agencies; what amount of federal bureaucracy or funding was needed; what choice consumers should have; and whether reforms should be immediate or phased-in. Carter was advised to acknowledge the internal debates but to promise that there would be no "deliberate slowdown."(30)

Conservatives, and those concerned about inflation, preferred a free market approach. Alain Enthoven of Stanford University proposed the Consumer Choice Health Plan, based on regulated competition among Health Maintenance Organizations (HMOs) and insurance plans. Tax credits or vouchers would be provided to permit enrollment in a benefit plan, and financial need of the poor would be addressed through higher tax credits or vouchers.

Rules would ensure that all people have a choice among competing alternatives

(which few have today); that they have good information on which to base

their choice; that competition emphasizes scope of benefits, quality of

services and total cost (as opposed to today's emphasis on preferred risk

selection ...).(31)

This program was based on the Federal Employees Health Benefits Plan and contained incentives for cost control by eliminating subsidies to expensive care (via tax breaks for employer premiums and Medicare/Medicaid cost reimbursement). It gave consumers an incentive to seek low-cost care by allowing them to retain the savings from vouchers or credits. While HEW doubted the benefits, it was supported by the Federal Trade Commission, which was skeptical about bureaucracy and regulation: "It is risky to assume that the apparent definitiveness of a regulatory scheme--which looks very good on paper--is a better guarantee of swift results than a properly functioning market."(32) Markets had a potential for efficiency, innovation, and cost control that no regulations could match. This approach received credibility as economic slowdown and reduced tax revenues increased fiscal pressures.

Indecision was evident as belated consultations began with Kennedy and Labor. Unions were suspicious of cost controls given the effects on hospital workers' wages, and they wanted comprehensive coverage, under public control to improve access at reduced cost. A phased-in plan must include an "immediate commitment to the total program and enough allocation of benefits and funds to the initial phase ... to gain control of the budgeting process."(33) UAW President Douglas Fraser reported "very disturbing stories emanating from Washington" about administration officials' desire to dilute NHI.(34) Kennedy was concerned that his credibility would be in doubt if he did not publicly query Carter's inaction. "He does not seem to be able to get on the same wavelength with Joe Califano on this issue, and feels that in the next few weeks he will be obliged to drop a bomb on us to stop criticism of his own seeming lack of activity."(35) Kennedy wanted contact with Bourne and Eizenstat, but they demured, since this would undermine Califano's ability to act as a "buffer," offend others in Congress, and link Carter too closely to the labor proposal.(36) Labor support had to be balanced against the concerns of budget advisers and congressional conservatives about expenditure. While HEW believed that a comprehensive bill could promote cost containment, most advisers sought a targeted approach with an initial phase covering those in need. Carter's advisers believed that labor leaders might make concessions on financing and private insurers, to reduce antipathy in Congress. But talks must proceed with care. "If labor is not supportive of our package, passage will be impossible from the start, probably ending the chance for NHI for a generation."(37)

Kennedy and Labor agreed to private insurers as administrators under federal regulation, with employer premiums.(38) Labor presented four general principles: comprehensive benefits and universal coverage; administration through the private sector (dismantling Medicare and Medicaid bureaucracies); regulation to ensure equal premiums, benefits, and high-quality care; and prospective budgeting with cost controls. Carter appreciated Labor's concession on private insurers but feared business resistance to regulation. However, proposed coverage of drugs, glasses, and dental care was too expensive, and prospective federal budgets for state-run programs were unfeasible. Carter avoided promises and confined further meetings to lower officials. HEW was given full responsibility: "The Administration is going to have to say `no' to labor on many issues, and it is preferable that the `nos' emanate from HEW rather than from the White House."(39)

Inflation and fiscal crisis affected planning. OMB argued that NHI would have minimal effects on health levels but had profound implications for inflation, unemployment, income, and investment. Thus, NHI should be considered part of Carter's fiscal and economic policy. The Kennedy-union proposal would increase spending from 21 percent to 27 percent of gross national product (GNP). The rise in health costs to over 9 percent of GNP was a problem, but the inflationary effects of spending were more immediate.(40) Budget advisers warned that "announcement of a National Health Plan which could be construed as committing the Administration to a broad health insurance plan, without consideration of economic conditions, would seriously undermine the credibility of our economic policies."(41) OMB wanted a phased-in plan, tailored to economic conditions. "We must make certain at each step of the way that our efforts to improve the nation's health are consistent with responsible policies to manage the budget and the economy.(42)

As the Congressional elections loomed, the Commerce Department argued that NHI would threaten Carter's anti-inflation program and his commitment to balanced budgets. NHI should be deferred because of "changes in economic conditions, the lack of budget resources ... and the need to balance national priorities." Carter should make a commitment to NHI at an unspecified time "when economic and budget circumstances permit."(43) Califano, also warned that inflation and taxpayer unrest would politically damage both NHI and the president. Califano urged the president to put the plan off until after the elections.(44) Bourne believed that NHI's reduced administration costs, prospective budgeting, elimination of waste, and preventative medicine would offset increased spending. A phased-in program would not generate political benefits. Coverage for the poor would be a mere extension of Medicare and Medicaid. "Out of control health costs would dictate that we could not implement the next stage of National Health Insurance and the accompanying controls."(45) Bourne feared that Carter's economic advisers would divert him from what was best for the public, and for his legacy. But Carter agreed to a phased-in program dependent on fiscal conditions. Carter ordered Califano to make cost controls paramount; new spending had to be offset by savings. Program financing should take account of the "ability of many consumers to share a moderate portion of the cost of their care."(46)

By late spring of 1978, congressional and labor leaders began to doubt Carter's commitment. Congressman James Corman, cosponsor of Kennedy's bill, felt excessive concern with budgets precluded delivery reform, cost controls, and "uniform, universal coverage." He termed health coverage a "right" and urged labor not to compromise.(47) Kennedy expected a comprehensive proposal by late August to permit fall hearings. Labor argued that health care could be a major campaign plank. A comprehensive NHI bill could force members of Congress to take a stand and face voters' judgment. But Carter's advisers felt that more time was needed to educate the public on the cost advantages of NHI. Congressional leaders also advised against a preelection bill; even a phased-in program would confuse the public and blur the president's image.(48)

Carter had to negotiate with others in Congress. Senator Russell Long supported catastrophic health insurance (the Long-Ribicoff bill), which preserved a role for private insurers and provided cost containment through co-payments and deductibles. He believed that this was the only bill that could "get out of the Senate Finance Committee, which he pointedly noted has far more jurisdiction over this subject than Senator Kennedy's Health Subcommittee."(49) Carter's advisers urged an evasive strategy, expressing support for universal comprehensive NHI, but outlining the economic and political constraints. The president had to walk a political tightrope, to avoid a public rupture with Kennedy and Labor, while delaying a pre-election bill.(50) The president hoped Kennedy would hold hearings on health care problems to dramatize weaknesses and build support for NHI. But serious disagreements developed with Kennedy and Labor. The White House proposed limited Medicaid reform and catastrophic coverage, with additional insurance phased in with separate legislation tailored to changing budget conditions. Kennedy accepted a phased-in program but rejected separate bills for each phase, which could give Congress (pressured by "special interest groups with overflowing war chests ready to oppose" NHI) the chance to renege on later stages. He was angry that Carter was considering automatic triggers to scuttle the plan under adverse fiscal conditions. Since this "cast doubts on the President's commitment to a program that is universal and comprehensive," Kennedy and his allies broke ranks with the president in the summer of 1978.(51)

Some White House officials considered compromises on principles if the split could be healed. Others urged going on without Kennedy, submitting a first draft bill for catastrophic coverage for the elderly and children. Kennedy's alternative could become moot, and Carter could take full credit for this accomplishment. Collaborative drafting of bills with Congress had not been successful. But Carter needed support from the Right to replace Kennedy. However, conservative senators opposed cost controls or regulation of private insurers and questioned Carter's goals on access.(52) To appease congressmen nervous about the election, Carter deferred consideration of NHI until after November. Given the confusion in committee assignments and legislative coalitions after the elections, the NHI plan was further delayed.

Development and Defeat of the NHI Proposal

After the elections, the administration remained divided. Califano called for a comprehensive, phased-in plan with immediate reforms consistent with future extensions. White House officials preferred a catastrophic health bill, with hospital cost containment. Phase 1 should be limited to improved Medicare and Medicaid benefits, catastrophic coverage for workers, and a preventative program. A comprehensive plan would not pass and would be a defeat for Carter going into the 1980 elections. Catastrophic coverage could be linked with cost and quality controls to reduce the gaps in Medicare and Medicaid.(53) HEW feared that a catastrophic bill precluded a comprehensive approach later. But the DPS felt this should not prevent fiscally responsible improvements. Carter was advised against study of a comprehensive approach, which would raise expectations:

During the several months of public scrutiny of the HEW tentative plan,

there would be a replay of last year's internal Administration battling

over the nature of a health plan. You could appear ineffective in imposing

realistic fiscal discipline even within the Executive Branch.

A "crisp, clear decision" was required to end the "infighting."(54)

Carter opted for the Phase 1 plan, which combined the Long-Ribicoff concern for fiscal restraint and catastrophic coverage and the Kennedy-Labor desire for comprehensiveness. However, the timetable was urgent since alternative plans were receiving committee scrutiny. "Only with a first phase plan, as opposed to a comprehensive bill, can we take the initiative away from Senator Long, who has introduced a catastrophic-only bill, and pass meaningful legislation in this Congress."(55) Califano was promised improved coverage for the aged and the poor. DPS outlined a commitment to a future comprehensive plan, to minimize criticism from liberals. But the plan was designed to appeal to conservatives, who wanted catastrophic coverage, user fees, and private insurer involvement. To Kennedy, Carter stressed commitment to the poor and uninsured, and the prospect for future expansion. To Long, fiscal prudence and the noninflationary character of the proposal were given priority.

It is our hope that, as national health plan legislation moves through the

Congressional process, the Administration proposal will attract a broad base

of support, both from those who think that Phase I is all we can do at this

time, and from those who wish to do more.(56)

When Kennedy resisted, attention was focused on Al Ullman and Charles Rangel, who emphasized cost controls and benefits for the poor. Long was urged not to oppose benefits for the poor that were crucial to House support. Labor leaders were urged to support the plan as a "significant first step" to a comprehensive plan.(57)

But while the gaps were narrowing, there were still debates in the executive. HEW proposed catastrophic coverage for the employed, those with low income, the unemployed, and the elderly. To ensure cost controls and efficiency, preventative care would be emphasized, Medicaid would be federalized, and Medicare and Medicaid would merge. Mandatory fee schedules would be set up, capital spending limits would be imposed on hospitals, federal reinsurance would be mandated for all insurers, and incentives for competition would be extended. HEW felt Carter should hold firm on coverage for the poor and House Speaker Tip O'Neil warned that liberals would block a bill that did not provide enough benefits. Nevertheless, OMB rejected federal control over Medicaid, increased regulation of health care, fee schedules, and voluntary cost controls. Compulsory fee schedules would not pass and could mobilize opposition to hospital cost containment, which was a vital part of Carter's anti-inflation plan. If Carter accepted HEW's plan and was forced to retreat, the political costs could be high.(58)

Carter offered concessions to liberals. Corman was courted with pre-natal and infant care and a possible future extension to children under six. Since Corman was a sponsor of the Kennedy plan and a leader on the House Ways and Means Committee, his support was vital. However, Carter also needed support from Long and Ribicoff if the plan was to pass the Finance Committee. Carter had to compromise or risk handing credit for Phase 1 to Long and the Republicans.(59) Carter, however, faced pressures to stall the initiative. Ullman wrote, "Congress is determined to balance the budget and seems unwilling to vote for a multi-billion dollar health plan this year or next."(60)

Nonetheless, the administration sent a National Health Plan to Congress, to protect Americans facing catastrophic illness or accident by requiring employers to purchase insurance for employees, with subsidized premiums for small business and public insurance for the unemployed. Coverage was extended to more low-income persons, by reducing the threshold to 55 percent of the poverty line. Aged citizens would be protected from physician billing above medicare fees. Prenatal, delivery, and infant care would be provided without deductibles, and extension of coverage to children under six was a "priority." Medicare and Medicaid were combined into federal health care, with competition and cost controls. New spending was deferred to 1983, to prevent inflation. The proposal did not commit the administration to a comprehensive insurance system. There were no mandatory caps on doctors' fees, with voluntary caps in Medicare and Medicaid only. However, a draft message to Congress and letters to supporters in unions and the liberal community suggested that the president's first phase plan created "both the framework and momentum for a universal, comprehensive national health plan."(61)

Senator Kennedy condemned the plan because it was inconsistent with a single-class health system. Catastrophic coverage, with fixed benefits, meant that wealthy persons paid a lower percentage of income for care. Doctors would be paid less for attending the aged and poor than the insured worker. Private insurers could charge differential premiums for those at high risk, "a form of sick tax, which violates a basic principle of national health insurance--to spread the risk equitably among all the people."(62) Carter's plan also did not budget for health costs through cost containment or fee controls. Most important, Kennedy could not accept that later phases would be adopted only if finances permitted. Kennedy promoted his Health Care for All Americans Act (96th Cong., 1st sess., S. 1720), with comprehensive coverage and cost controls.(63)

The White House proceeded cautiously to avoid criticism from Corman. But conservatives, emphasizing voluntarism and fiscal restraint, stalled the bill. The Finance Committee dropped maternal and infant benefits, and rejected federal control of Medicaid or catastrophic care. Conservatives believed that those who could not afford premiums or were refused coverage for preexisting conditions should be covered by private, statewide insurance pools. Carter was noncommittal to avoid a primary showdown with Kennedy. "Obviously any more aggressive discussions with Long and Ribicoff, if successful in reaching an agreement, would move us towards embracing the Committee bill and taking a proportionately greater share of the credit and/or blame."(64)

However, as the split with Kennedy worsened, negotiations with Long became more serious. HEW Secretary Califano was fired in July and replaced by Patricia Roberts Harris, who was not committed to a comprehensive national health plan. DPS urged cooperation with Long so that Carter would look "realistic, pragmatic and committed."(65) DPS favored the committee proposals for deductibles, 100 percent employer premiums, lower subsidies, earlier starting date, and federally regulated statewide insurance pools. Lower benefits for the aged and poor, and elimination of neonatal benefits or cost controls, were unacceptable. But conflicts among committee members extended the hearings into 1980. While the committee initially wanted a 1981 starting date, inflation and fiscal shortfalls made this unlikely, and Republicans sought to delay or reduce spending. By the summer of 1980, it was clear that no national health legislation would be reported out of committee before the election.

The House and Senate did act to protect seniors from unscrupulous insurance providers and prohibited the sale of excess coverage, misleading representation of policies as government sanctioned, and fraudulent mail orders, with a voluntary insurer certification program. Carter supported these changes, which corrected costly abuses.(66) Ullman and Durenberger introduced pro-competition tax changes to give subscribers incentives for economizing. Alfred Kahn, Carter's inflation adviser, supported bills that stimulated competition among insurers and shopping by employees. But DPS and HEW were opposed, since these bills would reduce the available coverage unless comprehensive reforms were introduced. The White House was again preoccupied with internal debate, but decided to sell a national health plan as a cure for inflation.(67)

The plan, however, secured little support. While too broad for conservative Democrats, it seemed to liberals like an abandonment of the ideals of comprehensive NHI.(68) Carter turned to other issues, notably cost containment. Despite this preelection emphasis on fiscal responsibility, Carter's advisers wanted to preserve the prospects for a plan to increase coverage for the poor. In an election campaign, it was wise to avoid raising doubts about Carter's commitment to a national health plan.(69) To the last minute, Carter did not side with the Left or the Right, as health policy was secondary to politics. This indecision was fatal, since bold decisions were unpalatable as elections neared.

Assessing the Quality of Presidential Leadership

Thus, the Carter administration failed to pass health care legislation in a Congress controlled by Democrats. It remains to evaluate the importance of "agency" factors that Carter could have altered--leadership, the timing of proposals around elections, administrative unity and organization, and management of relations with Congress--as opposed to "structural" constraints beyond his control--the political strength of the president, fiscal and, economic constraints, and institutional arrangements in Congress, which have thwarted recent presidents of varying character, dispositions, and abilities.

Carter was uncomfortable with the compromises demanded by all sides and took months to develop his health care proposals. Initially, he favored a comprehensive review by departments and cabinets, which proved time-consuming. By delaying, he squandered the goodwill of the honeymoon period (limited though it was because of his narrow victory) and reduced the political and fiscal feasibility of the program. Health costs rose, making the program more costly and delaying the benefits of cost containment from a rationalized system. The economy did not recover enough to lessen fiscal pressures and inflation. The delays produced insoluble problems of timing, given the midterm elections and primaries. It cost Carter support, dividing liberals, while conservatives united around less-inflationary options. By the time a proposal was submitted to Congress, it was too late to build the support needed to pass the legislation as Congress feared the wrath of voters and interests if it passed a plan that was either not comprehensive or too inflationary.

Carter was unable to get his assistants and agencies to cooperate in support of his health care goals. He delegated policy making to cabinet departments in a bid to move away from Nixon's imperial White House. DPS had no power to impose unity and compromise among agencies. This situation improved after 1978, but only after the invaluable honeymoon period had been squandered. Carter expected comprehensive proposals to emerge from this incoherent organization. He authorized drafting of different proposals--compulsory and voluntary, public and private, comprehensive and selective. This reinforced rifts in the administration, as agencies backed different draft plans. This led to moves by OMB and the Council of Economic Advisors (CEA) to resist concessions to Democratic constituencies like Labor. When White House views became clearer after mid-1979, the timetable for passage was not fortuitous.

The White House had too little experience to steer complex proposals through Congress. Presidential relations with Congress have been problematic since the constitution was written. But different presidential styles can contribute to success or failure in securing approval for the president's legislative projects. Jones contrasts two presidential responses to Congress. Jones's first style is a president sympathetic to the electoral fixation and pragmatism of Congress, aware of the vicissitudes of congressional coalitions and prepared to develop compromise policies, not ideal proposals. This style contributed to Lyndon Johnson's success in promoting Medicare. Jones's second type is the "trusteeship" president, who sees his office as representing the public interest as against short-term, political calculus. Such a president is not sympathetic to the electoral fixation of congressmen and finds it hard to work in partnership with them to seek pragmatic policy compromises.(70) Carter was a principled outsider who preferred defeat on principles to victory via compromise. He abhorred special interest politics and criticized the parochial orientation of Congress. This "trustee" approach limited Carter's willingness to negotiate on complex, controversial measures like health care.

Much of the first year was spent developing a feeling for Congress. During this time, the administration attitude was one of "omniscience" as unexpectedly victorious outsiders. The tendency to overload Congress and to engage in confrontation with allies made the honeymoon unproductive. Carter's early problems were blamed on his choice of White House staff "Mistakes made by the young administration were universally attributed to inexperience and unfamiliarity with the complexities of national issues and institutions, particularly Congress."(71) Legislative liaison staff was particularly ineffectual, with the appointment of Georgians who were "out of their depth" in dealing with Congress.(72) Liaison staff was not prepared for the volume and nature of its work.(73) This lack of familiarity with Congress was evident in health policy. Carter sought ideal proposals without pragmatic compromises and set unrealistic timetables for committee approval. As on other bills, his trusteeship style of leadership in the national interest alienated the electorally focused Congress.(74) Efforts were made after the first year to improve relations with Congress and to take account of its electoral fixation. But by this time, elections were close and the window of opportunity for bold initiatives like health insurance had been lost.(75)

Carter scored a narrow victory over Gerald Ford. This gave liberal Democrats the belief that he owed them for their support and would reward them with liberal policies. But the administration had to adjust to the conservative trend in political discourse. Carter wanted to hold to his themes of fiscal prudence and efficiency, heralding the splits in the administration. Carter's constant efforts to keep liberals allied to the party while adhering to the "outsider, neoliberal themes of government efficiency and frugality" caused the administration's vacillation.(76) His approval rating after inauguration was lower than other recent presidents and he had a brief honeymoon, ending with the Bert Lance affair of August 1977.(77) At first, Carter focused on the Democratic constituency of labor and the poor. Ultimately, Carter's aides believed that congressional conservatives were more important in this inflationary situation and fiscal prudence became paramount. This divided Carter from core supporters like Labor, while not appeasing conservatives.(78) Carter's unpopularity further weakened him in Congress; as Peterson observes, "Truly unpopular presidents ... have quite a challenge demonstrating the effectiveness of their legislative skills."(79)

The economic decline in the 1970s produced economic stagnation, inflation, and fiscal crisis. This was a difficult context for a massive new commitment like national health insurance. Simultaneous inflation, with recession and fiscal deficits, eliminated the Keynesian option of economic stimulus. The severe recession undermined revenues, while inflation pushed up costs.(80) This affected Carter's choices in health care, as he pushed for cost containment, and a limited form of NHI. But Carter did not adjust soon enough to succeed before electoral pressures and legislative timetables proved decisive. Economic problems led to the ascent of economic advisers over domestic policy advocates. Inflation gave more weight to those favoring fiscal conservatism. From mid-1978, "the Carter approach begins to look like it is paving the way for Reaganism, as worried attention to the generation of economic growth virtually overwhelms all other domestic priorities."(81)

Whatever the ability of presidents, Congress is independent and not subject to control. This was all the more so in the 1970s, given the desire to tame the imperial presidency, which had caused the excesses of Watergate and Vietnam. Strong congressional figures in his own party, notably Kennedy and Long, nullified the advantage of working with Democrats. Carter confronted a Congress that was more interventionist in policy than before, because of the decline of presidential prestige, the influx of new members, and institutional reforms. Opponents very early on challenged him, and his posture as outsider-trustee did nothing to alleviate this situation. The presidential ambitions of Senator Kennedy also gave him an incentive to undermine Carter's credibility. Senator Kennedy had little motivation to cooperate once it was apparent that Carter was vulnerable to a challenge in the primaries; Kennedy believed that a principled stance would contribute to success with important Democratic constituencies disillusioned with Carter's rightward drift. But reforms to the legislative process made it more difficult for Carter to exert leadership. Decentralization of power in Congress meant that Carter had to negotiate with many strong leaders in committees and subcommittees, as the new arrangements hampered legislative coalition building. As Peterson observes, these trials heralded a more confrontational relationship between the president and Congress, which has persisted since Carter's administration in an era marked by the "reduced effectiveness of the president as a legislative player."(82)

Conclusions

Structural constraints and the choices that Carter made in organizing his presidency, presenting his legislative program, and negotiating with Congress all affected his successes and failures. Institutional factors, like the frequency of House and Senate elections, and the power of congressional committees, certainly affect the probability of legislative success. An electoral image is always paramount, sharpened by biannual congressional and Senate races, and the extended primary season. Economic constraints, notably the post-Vietnam, post-oil embargo limits on fiscal capacity and economic performance, also worked against Carter since thorough reform of health care was costly. He was also not aided by the narrow electoral victory or by his plunging popularity, caused by the intractable economic crisis of the time.

However, presidential goals may be achievable with appropriate timing, administration unity, and astute congressional liaison. Carter's unwillingness to compromise or to share credit with Congress proved disastrous to health care and other initiatives. Carter's attention to detail induced time-consuming planning, which worked against the tight congressional timetable and wasted his brief "honeymoon." His failure to centralize planning fragmented executive efforts and permitted opponents and interest groups to exploit divisions and delay the national health plan. His failure to rapidly impose a decision on recalcitrant administration actors and his confrontational style with Congress did little to enhance the credibility of the initiative.

As Stephen E. Ambrose concludes, detailed examination of archival sources indicates that "the more one learns about the Carter presidency, and the deeper into his administration one goes, the worse Carter looks."(83) While he faced complex political and economic challenges, Carter's leadership style did little to contribute to his success. As Kaufman argues, the Carter administration often appeared to be in disarray, divided and directionless, lacking the leadership necessary for effective influence in Congress.(84) The evidence presented here supports this assessment, while illustrating the constraints that have limited the effectiveness of other presidents.

It is unclear how important health policy was to Carter. He was a late convert, whose cautious instincts worked against a strong commitment to an NHP His election promise was deliberately vague and favored a limited, fiscally responsible variant. Carter was cautious because health care "had never interested him and was expensive as well."(85) Recent analyses of Carter's record indicate that he was capable of success when he believed in something, especially in his first two years, when "Carter lobbied for and achieved everything he wanted on issues he seriously cared about.(86) Carter's lukewarm commitment did nothing to advance health reform. Perhaps his indecision in this field reflected the low priority he assigned to this legislative goal.

Analysts must avoid a deterministic interpretation of the impact of institutions and economic and political conditions. These structures set conditions and boundaries on the actions of decision makers. The division of powers, the frequency of congressional elections and concern for electoral standing, and the power of committees and congressional alliances may limit executive leadership in domestic policy making outside of crises. This is especially so in recent times, as the economic growth that sustained activist presidents has subsided and fiscal constraints have tightened in a system with increased congressional independence. Many of those close to Carter refer to the difficult legislative climate of the times to explain policy reversals.(87) Success or failure also reflects the abilities of leaders to adjust to these constraints. The convictions, choices, and skills of presidents are important to policy outputs. Personal experiences and styles of leaders will go far to determining what they can accomplish. The constitution and the economy may be constraints, but the organization and effectiveness of the executive are under presidential control. The powers that a president gives to agencies and officers, and his efforts to cooperate with Congress, remain crucial determinants of legislative success.

Historical analyses can illuminate the relative importance of structure and leadership in influencing policy. If Carter had been a different leader with differing priorities, management styles, ideology, and disposition in dealing with the electoral fixation and constituency and an interest group focus of Congress, his health care endeavors might have been more fruitful. Nonetheless, success would not have been guaranteed. Even an effective leader might not have secured comprehensive health care reforms in this era, given the congressional systems' bias against nonincremental policy change.

Notes

(1.) Gary W. Reichard, "Early Returns: Assessing Jimmy Carter," Presidential Studies Quarterly 20, no. 3 (1990):603-51.

(2.) Edwin Hargrove Jimmy Carter as President: Leadership and the Politics of the Public Good (Baton Rouge: Louisiana State University Press, 1988), p. 4.

(3.) Stephen Skowronek, "Presidential Leadership in Political Time," in The Presidency and the Political System, 4th ed., ed. Michael Nelson (Washington, DC: Congressional Quarterly Press, 1995), p. 158.

(4.) Reichard, "Early Returns," p. 610; Russell D. Motter, "Jimmy Carter in Context," Mississippi Quarterly 45, no. 4 (1992): 467-85.

(5.) Hargrove, Jimmy Carter as President, pp. 13-14.

(6.) Ann Mari May, "Fiscal Policy, Monetary Policy, and the Carter Presidency," Presidential Studies Quarterly 23, no. 4 (1993): 699-712.

(7.) Shirley Anne Warshaw, "The Carter Experience with Cabinet Government," in The Presidency and Domestic Policies of Jimmy Carter, ed. Herbert Rosenbaum and Alexej Ugrinsky (Westport, CT: Greenwood, 1994), pp. 376-78.

(8.) Colin Campbell, Managing the Presidency: Carter, Reagan, and the Search for Executive Harmony (Pittsburgh: University of Pittsburgh Press, 1986), pp. 59-64; Warshaw, "The Carter Experience," pp. 380-85; James W. Riddlesperger and James D. King, "Political Constraints, Leadership Style and Temporal Limits: The Administrative Presidency of Jimmy Carter," in The Presidency, ed. Rosenbaum and Ugrinsky, p. 371.

(9.) Haynes Johnson, In the Absence of Power: Governing America (New York: Viking, 1980), p. 317.

(10.) Burton I. Kaufman, The Presidency of James Earl Carter (Lawrence: University of Kansas Press, 1993), p. 3.

(11.) Mark J. Rozell, "President Carter and the Press: Perspectives from White House Communications Advisors," Political Studies Quarterly 105, no. 3 (1990): 419-34.

(12.) Michael Genovese, "Jimmy Carter and the Age of Limits: Presidential Power in a Time of Decline and Diffusion," in The Presidency, ed. Rosenbaum and Ugrinsky, p. 187.

(13.) Edwin C. Hargrove, "The Carter Presidency in Historical Perspective," in The Presidency, ed. Rosenbaum and Ugrinsky, p. 22.

(14.) Alan Wolfe, America's Impasse: The Rise and Fall of the Politics of Growth (New York: Pantheon, 1981), pp. 209-212, 228-29.

(15.) Mark A. Peterson, "The President and Congress," in The Presidency and the Political System, ed. Nelson, p. 456.

(16.) David Banta, "The Federal Legislative Process and Health Care," in Health Care Delivery in the United States, ed. Steven Jonas (New York: Springer, 1977), p. 343.

(17.) William F. Grover, The President as Prisoner: A Structural Critique of the Carter and Reagan Years (Albany: SUNY Press, 1989), p. 124.

(18.) William Grover and Joseph G. Peschek, "The Rehabilitation of Jimmy Carter and the Limits of Mainstream Analysis," Polity 23, no. 1 (1990): 148.

(19.) Judith Feder, John Holahan, and Theodore Marmor, eds., National Health Insurance: Conflicting Goals and Policy Choices (Washington, DC: Urban Institute, 1979), p. 7.

(20.) Jimmy Carter Presidential Campaign, "Address by Jimmy Carter on National Health Policy before the Student National Medical Association," Washington, DC, April 16, 1976.

(21.) Hargrove, Jimmy Carter as President, pp. 33-36.

(22.) Austin Ranney, "The Carter Administration," in The American Elections of 1980, ed. A. Ranney (Washington, DC: American Enterprise Institute, 1981), p. 10.

(23.) Senator J. Corman to Carter, February 4, 1977; S. Eizenstat to J. Powell (White House Press Secretary), February 1977; Jimmy Carter Library (JCL), White House Central Files (WHCF) Executive (EX) IS1 File IS1 1/20/77-6/30/77; Charles O. Jones, The Trusteeship Presidency:Jimmy Carter and the United States Congress (Baton Rouge: University of Louisiana Press, 1988), p. 164.

(24.) S. Eizenstat to Carter, September 19, 1977, JCL WHCF SUBJECTS IS1 (Box IS2) EX IS1 7/1/77-10/31/77; S. Eizenstat, J. Onek (Domestic Policy Staff Files [DPS]), J. McIntyre (Director, Office of Management and Budget [OMB]) to Carter, November 9, 1977;JCL WHCF Staff Secretary Handwriting, box 59, file 11/9/77.

(25.) P. Bourne to H. Jordan (White House Chief of Staff), April 17, 1978; JCL WHCF Subjects EX IS1 4/11/78-6/30/78; Bourne to Jordan and Eizenstat, August 1, 1977; JCL WHCF DPS Eizenstat, National Health Insurance (NHI) [O/A 7431] [1].

(26.) Bourne to Jordan and Eizenstat, August 1, 1977; Eizenstat to Jordan and Bourne, August 2, 1977; JCL WHCF DPS Eizenstat, NHI [O/A 7431] [1].

(27.) Joe Onek and Bob Havely to S. Eizenstat, September 8 and September 27, 1977; JCL WHCF EX IS1 7/1/77-10/31/77.)

(28.) P. Bourne to H. Jordan, April 17, 1978; JCL WHCF EX IS1 4/11/78-6/30/78.

(29.) J. Califano to Carter, April 5, 1978; JCL WHCF Handwriting File 4/6/78, [1].

(30.) Eizenstat, Havely, and Onek to Carter, December 20, 1977; JCL WHCF DPS Eizenstat, NHI [O/A 7431] [2]; S. Eizenstat J. Onek, and J. McIntyre to Carter, November 9, 1977; JCL WHCF Handwriting, box 59, file 11/9/77 [2].

(31.) A. Enthoven to Secretary Califano, September 22, 1977; JCL WHCF DPS Eizenstat.

(32.) Michael Pertschuk to J. Onek, May 4, 1978; J. E. Gaines to M. Pertschuk, May 4, 1978.

(33.) Melvin Glasser to Peter Bourne, November 18, 1977; "Organized Labor's Views on an Essential Minimum for a National Health Insurance Program" (attached); JCL WHCF DPS Bourne, box 41, file NHI 10/28/77-7/7/78 [O/A 6047].

(34.) "UAW Will Oppose Any Effort to Postpone or Weaken Proposals for National Health Security," News from UAW, December 13, 1977.

(35.) Bourne to H. Jordan, June 20, 1977; JCL WHCF DPS Eizenstat, NHI [CF, O/A 40].

(36.) Kennedy to Eizenstat, November 17, 1977; December 7, 1977; JCL WHCF DPS Eizenstat, NHI [O/A 7431] [1] Eizenstat to Jordan, July 5, 1977; Jordan to Bourne, July 8, 1977; JCL WHCF DPS Eizenstat, NHI [CF, O/A 40].

(37.) S. Eizenstat et al. to Carter April 6, 1978; Re: Meeting with Senator Kennedy and Organized Labor, p. 3; JCL WHCF Handwriting File 4/6/78 [1]; Eizenstat to Carter, February 8, 1978; Bourne to Eizenstat, February 4, 1978; JCL WHCF DPS Eizenstat, box 241, file NHI 1/78-2/78 [O/A 7431]; Eizenstat to Carter, May 31, 1978; Staff Secretary, Handwriting, box 88, June 1, 1978.

(38.) J. Onek and B. Havely to S. Eizenstat, March 9, 1978; JCL WHCF DPS Eizenstat, box 241, file NHI 3/78 [O/A 7431].

(39.) S. Eizenstat et al. to Carter, April 6, 1978, p. 6; Califano to Carter, April 5, 1978; J. Onek to S. Eizenstat, April 26, 1978; JCL WHCF EX IS1 4/11/78-6/30/78; S. Eizenstat to Carter, May 31, 1978; JCL WHCF, Staff Secretary, Handwriting, box 88, June 1, 1978.

(40.) Carter to Senator H. Talmadge, October 11, 1977; JCL WHCF EX IS1 7/1/77-10/31/77; R. Dove to T. Jones, May 22, 1978, JCL WHCF DPS Eizenstat, box 242, file NHI 8/78-12/78 [O/A 7431]; Jim McIntyre to Carter, April 5, 1978; JCL WHCF Handwriting, file 4/6/78 [I].

(41.) C. Schultze (Chair, Council of Economic Advisors [CEA]) and J. McIntyre to Carter (June 1978); JCL WHCF DPS Eizenstat, box 242, file NHI 6/78 [O/A 7431] [I].

(42.) C. Schultze and J. McIntyre to Carter June 30, 1978; JCL WHCF DPS Eizenstat, box 242, file NHI 6/78 [O/A7431] [I].

(43.) Sidney Harman, Assistant Secretary for Policy, Department of Commerce to Carter, n.d. May 1978; J. McIntyre to Carter, June 1, 1978; JCL WHCF, Staff Secretary, Handwriting, box 88, June 1, 1978.

44.) J. Califano to Carter June 26, 1978; JCL WHCF DPS Eizenstat, box 242, file NHI 6/78 [O/A7431] [I].

(45.) P. Bourne to Carter June 29, 1978; JCL WHCF DPS Eizenstat, box 242, file NHI 6/78 [O/A7431] [3].

(46.) Presidential Directive DPS-3 July 29, 1978; Carter, Remarks at Forth Worth Luncheon June 1978; attached to Califano to Carter, June 26, 1978.

(47.) J. Corman to D. Fraser, May 17, 1978; JCL WHCF EXEC IS1 4/11/78-6/30/78.

(48.) S. Eizenstat and J. Califano to Carter, July 1978; JCL WHCF DPS Eizenstat, box 242, file NHI 7/78 [O/A 7431] [1]; for a summary of congressional advice, see Califano to Carter, May 15, 1978; JCL WHCF, Confidential IS1 1/20/77-1/20/81.

(49.) Califano to Carter, May 15, 1978.

(50.) J. Onek and S. Eizenstat to Carter, June 25, 1978; JCL WHCF, DPS Eizenstat, box 242, file NHI 6/78 [O/A 7431] [2].

(51.) Press Release, Statement of Senator Edward M. Kennedy July 28, 1978; JCLV WHCF DPS Eizenstat, box 242, file NHI 7/78 [O/A 7431] [1]; S. Eizenstat and J. Califano to Carter, July 1978; JCL WHCF DPS Eizenstat, box 242, file NHI 7/78 [O/A 7431] [1]; Eizenstat and J. Onek to Carter, July 28, 1978; JCL WHCF DPS Eizenstat, box 242, file NHI 7/78 [O/A 7431] [1].

(52.) J. Onek to S. Eizenstat, n.d. July 1978; R. Moe to the vice president, August 14, 1978; JCL WHCF DPS Eizenstat, box 242, file NHI 8/78-12/78 [O/A 7431]; S. Eizenstat to the vice president, August 22, 1977, JCL WHCF DPS Eizenstat, box 242, file NHI 8/78-12/78 [O/A 7431].

(53.) Onek to Carp, December 4,1978; JCL WHCF Eizenstat, file NHI [CF, O/A 7291 [4].

(54.) Eizenstat et al. to Carter January 17, 1979; JCL WHCF DPS Handwriting, box 15, file 118/79; Eizenstat to Mondale, December 5, 1978; JCL WHCF Eizenstat NHI 8/78-12/78; Califano to Carter January 8, 1979.

(55.) Eizenstat to Carter, February 22,1979; JCL WHCF DPS Eizenstat, NHI [CF, O/A 729] [31; Powell to Carter, May 18, 1979; JCL WHCF Handwriting, box 132, file 5/23/79 [2].

(56.) "Talking Points: Introduction of Kennedy Health Plan: Congressional Interest," May 15, 1979; JCL WHCF, DPS Eizenstat, NHI [CF, O/A 729] [3]; Eizenstat and Onek to Carter, March 20, 1979; JCL WHCF, DPS Eizenstat, NHI [CF, O/A 729] [2].

(57.) Eizenstat to Carter June 9, 1979; Moore and Eizenstat to Carter June 6, 1979; Eizenstat to Carter June 5, 1979; JCL WHCF EXEC IS1 5/1/79-6/30/79.

(58.) McIntyre to Carter, May 15,1979; JCL WHCF, DPS Eizenstat, NHI [CF, O/A 729] [3]; Califano and Eizenstat to Carter, May 23, 1979; Eizenstat and Moe to Carter, May 23,1979; McIntyre, Schultze, Blumenthal (Secretary of the Treasury), and Kahn to Carter, May 23, 1979; JCL WHCF Handwriting, box 133, file 5/25179 [2]. Schultze to Eizenstat, May 19, 19700; JCL WHCF Eizenstat, file NHI [CF O/A 729] [2].

(59.) Califano to Carter June 6, 1979; Moe to Carter June 6,1979; Eizenstat and McIntyre to Carter June 8, 1979; JCL WHCF Handwriting, file 6/8/79 [1]; Eizenstat, Moore, and Moe to Carter, May 16, 1979; JCL WHCF DPS Eizenstat NHI [CF, O/A 7291 [3]; Eizenstat to vice president, December 5, 1978; JCL WHCF Eizenstat, file NHI 8/78-12/78.

(60.) Ullman to Carter, June 5, 1979; JCL WHCF EXEC IS1 file IS1 5/1/79-6/30/79.

(61.) Jimmy Carter, Draft Message to the Congress of the United States; the Carter Administration's Outline of a Fully Implemented National Health Plan; S. Eizenstat to Carter, Re: National Health Plan Letters, June 9, 1979;JCL WHCF Handwriting, file 6/13/79.

(62.) Statement of Senator Edward M. Kennedy on the President's National Health Care Proposals June 12, 1979.

(63.) Stuart E. Eizenstat, "President Carter, the Democratic Party and the Making of Domestic Policy," in The Presidency, ed. Rosenbaum and Ugrinsky, p. 13; Statement of Edward M. Kennedy on National Health Insurance before the Senate Finance Committee, June 21, 1979.

(64.) Mongan to Eizenstat and Camp, November 9, 1979; JCL WHCF Eizenstat National Health Plan [CF, O/A 729] [3].

(65.) Berenson to Eizenstat, August 14, 1979; "Comparison of Administration (National Health Act) and Kennedy (Health Care for All Americans Act) Proposals," September 27, 1979; JCL WHCF Eizenstat, National Health Plan [CF, O/A 7291 [2].

(66.) Eizenstat to Claude Pepper, May 21, 1980; Attached: Select Committee on Aging, News, May 1, 1980. JCL WHCF EXEC IS1 4/1/80-1/20/81.

(67.) A. Kahn to W. Miller (Secretary of the Treasury), P. Harris et al., June 26, 1980; Eizenstat to A. Kahn et al., July 11, 1980; P. Harris to A. Kahn et al., June, 1980; JCL WHCF EXEC IS1 4/1/80-1/20/81. Mongan to Eizenstat and Carp, March 4 and March 12, 1980; JCL WHCF Eizenstat, file NHI [CF, OVA729] [1].

(68.) Eizenstat, "President Carter," p. 13.

(69.) Eizenstat to Kahn, Miller, Harris, et al., July 11, 1980; JCL WHCF EXEC IS1 4/1/80-1/20/81.

(70.) Jones, The Trusteeship Presidency, p. 4.

(71.) Bruce Adams and K. Kavanaugh-Baran, Promise and Performance: Carter Builds a New Administration (Lexington, MA: Lexington Books, 1979), p. 44.

(72.) Eric Davis, "Legislative Liaison in the Carter Administration," Political Science Quarterly 94, no. 2 (1979): 292, 299.

(73.) Paul J. Quirk, "Presidential Competence," in The Presidency and the Political System, ed. Nelson, pp. 18788; Tinsley Yarbrough, "Carter and the Congress," in The Carter Years: The President and Policy Making, ed. M. G. Abernathy, Dilys Hill, and Phil Williams (New York: St. Martin's, 1984), p. 166.

(74.) See Christopher Caplinger, "The Politics of Trusteeship Governance: Jimmy Carter's Fight for a Standby Rationing Plan," Presidential Studies Quarterly 26, no. 3 (1996): 786, 791.

(75.) Jones, The Trusteeship Presidency, pp. 213-14.

(76.) Eizenstat, "President Carter," p. 8.

(77.) Ranney, "The Carter Administration," p. 7.

(78.) Martin Halpern, "Jimmy Carter and the UAW: Failure of an Alliance," Presidential Studies Quarterly 26, no. 3 (1996): 771.

(79.) Peterson, "The President and Congress," p. 458.

(80.) John Aldrich and Thomas Weko, "The Presidency and the Election Campaign: Framing the Choice in 1992," in The Presidency and the Political System, ed. Nelson, p. 259; Paul Quirk and Bruce Nesmith, "Divided Government and Policy Making: Negotiating the Laws," in Ibid., pp. 544-46; Paul Light, The President's Agenda: Domestic Policy Choice from Kennedy to Carter (Baltimore: John's Hopkins University Press, 1982), pp. 1-12.

(81.) Grover and Peschek, "The Rehabilitation of Jimmy Carter," p. 123.

(82.) Peterson, "The President and Congress," p. 461.

(83.) Stephen E. Ambrose, "The Presidency of James Earl Carter," Foreign Affairs 72, no. 4 (1993): 160.

(84.) Kaufman, The Presidency of James Earl Carter, p. 3.

(85.) Eizenstat, "President Carter," p. 13.

(86.) Shoup, cited in Reichard, "Early Returns," p. 611; Mark J. Rozell, "Carter Rehabilitated: What Caused the 39th President's Press Transformation?" Presidential Studies Quarterly 23, no. 2 (1993): 317-31.

(87.) Davis, "Legislative Liaison," p. 300; Rozell, "Carter Rehabilitated," p. 431.
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Title Annotation:Wheeling and Dealing in the White House; Jimmy Carter
Author:Finbow, Robert
Publication:Presidential Studies Quarterly
Date:Jan 1, 1998
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